Welcome to The Bariatric Surgery Program at the Mayo Clinic Campus in FloridaJacksonville, Florida

by Gretchen E. Ames, PhD, ABPP, and Enrique F. Elli, MD, FACS, FASMBS

Dr. Ames is the psychologist for the program and Dr. Elli is the Director of Bariatric Surgery for the Bariatric Surgery Program at the Mayo Clinic Campus in Jacksonville, Florida.

FUNDING: No funding was provided.
DISCLOSURES: The author reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2016;13(12):18–21.

This column is dedicated to featuring accredited bariatric centers around the world, with a focus on their facilities, staff, statistics, processes, technology, and patient care.

Welcome to The Mayo Clinic Campus in Florida

Mayo Clinic Campus
The Mayo Clinic Campus in Florida is a not-for-profit hospital and outpatient clinic serving the southeastern United States and international patients from 143 countries. The staff includes 495 physicians and scientists and 4,664 allied health professionals serving more than 106,000 patients annually. According to the U.S. News and World Report 2016, Mayo Clinic in Jacksonville, Florida is ranked the No. 1 hospital in Jacksonville. The hospital, which opened in 2008 bringing inpatient and outpatient services together on one campus, has 304 beds and 22 operating rooms. The outpatient clinic and hospital offer more than 35 adult medical and surgical specialties as well as a full-service emergency department. Our bariatric surgery program began in 2007 and earned Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accreditation in January of 2016. Mayo Clinic has two other campuses offering bariatric surgery programs with MBSAQIP accreditation located in Rochester, Minnesota and Scottsdale, Arizona.

The bariatric surgery program team is integrated and multidisciplinary consisting of four surgeons, an obesity medicine specialist, two advance practice providers, two bariatric dietitians, a bariatric nurse navigator, a surgical nurse, a clinical health psychologist, MBSAQIP clinical reviewer, and an insurance specialist. Our team participates in biweekly patient care rounds and monthly bariatric board meetings where we discuss the most difficult cases of the month, such as patients with high medical complexity (e.g., transplant patients), body mass indices (BMIs) more than 60kg/m2, patients with limited mobility, and nonresponse to primary bariatric operations.Surgeons. Enrique F. Elli, MD FACS, FASMBS, and Steven P. Bowers, MD, FACS, are board certified general surgeons who perform minimally invasive foregut operations and primary bariatric operations including RYBG, VSG, and DS. They also perform revision and conversion operations for patients who were nonresponders or suffered medical complications with primary bariatric operations. Dr. Elli, Director of Bariatric Surgery, came to Mayo Clinic in February 2016 from the University of Illinois at Chicago and was the first surgeon in our community to offer robotic RYGB. Additionally he serves as a site reviewer for MBSAQIP. With an increase in demand in VSG in recent years, Horacio J. Asbun, MD, FACS, and John A. Stauffer, MD, FACS, also perform this operation for our program.Obesity Medicine Specialist. Scott A. Lynch, MD, MPH, Director of Obesity Medicine and Nutrition, is board certified in obesity medicine. He performs medical evaluations for patients considering bariatric surgery in our program. Once testing has been completed, Dr. Lynch provides documentation of medical necessity for surgery. Dr. Lynch also provides medical management for our preoperative liquid meal replacement diet.Advance Practice Providers. Lisa C. Arasi, DNP, ARNP, and Tina M. Osborn, PA, perform medical evaluations for patients considering bariatric surgery in our program. Their other duties involve medical monitoring for the pre-operative liquid meal replacement protocol, assisting the surgeons in clinic and with hospital discharge, and providing follow-up care for patients after their operation.Dietitians. Lori H. Solem, RD, and Courtney J. Young, RD, perform initial individual nutrition evaluations for all patients who desire bariatric surgery. They facilitate four hours of group-based education to prepare patients for dietary changes required for optimal outcome after bariatric surgery and provide one-on-one teaching for patients who need additional assistance with dietary change. Their other duties include providing individual nutrition follow-up care after the operation and co-facilitation the postsurgery support groups.Bariatric Nurse Navigator. Lisa A. Leath, RN, CCTC, worked as a certified clinical transplant coordinator before joining the bariatric team in August 2016. She created a database for tracking patient flow and helps our patients navigate the 3 to 6 month presurgical work-up process. Her other duties consist of completing metabolic rate testing, preoperation liquid meal replacement diet teaching, and chart review in preparation for insurance submission.Surgical Nurse. Megan J. Renwick, RN, provides support for Drs. Elli and Bowers in clinic. Her duties include assistance during surgical consultation and informed consenting, surgery scheduling, and perioperative patient care.
Clinical Health Psychologist. Gretchen E. Ames, Ph.D., ABPP, is board certified in clinical health psychology. She performs the initial psychology consultation for every patient who desires a bariatric operation. She also leads four hours of group-based education preparing patients for lifestyle changes required for optimal outcome after surgery and provides individual follow-up for patients suffering from psychological problems (e.g., binge eating, depression) that may interfere with adherence lifestyle change recommendations. Dr. Ames co-facilitates the monthly post-bariatric surgery groups for patients with Lori Solem, RD.Bariatric Clinical Reviewer. Cindy Cline joined the team as the Bariatric and Metabolic Surgery Clinical Reviewer (MBSCR) in January 2016. She participates in the quarterly MBSAQIP meetings and collates program data, including the number and type of operations performed, complications, and hospital readmissions, for the team to review at our monthly meeting. These data are critically important for identifying program strengths as well as potential areas for quality improvement projects. Prior to accepting her current position, Ms. Cline served as the program clinical assistant and coordinator and was instrumental in the preparation of our MBSAQIP application and for our site visit.Insurance Submission Coordinator. Karen Franco, our financial and revenue cycle coordinator, is responsible for collating the documentation of medical necessity for our patients and submitting to their insurance companies for predetermination and authorization for surgery. Ms. Franco has considerable knowledge of the requirements for insurance providers in our area and often assists with problems or denials and helps patients navigate the appeal process when needed.

Patient Care Process
Our program accepts self-referrals or physician referrals from the local community, the southeastern United States, and internationally. We also receive internal referrals from our out-patient practice from many different specialties, such as internal medicine, family medicine, transplant, cardiology, endocrinology, pulmonology, gastroenterology, hemotology/oncology, orthopedic surgery, urology, physical medicine and rehabilitation, neurology, and pain medicine. Our patient process is as follows:1. Medical. All patients undergo an initial medical evaluation with Dr. Lynch, Lisa Arasi, ARNP, or Tina Osborn, PA. During this visit, a discussion and shared-decision about which operation is most appropriate occurs in the context of the patient’s medical problems, tolerance for risk, desired weight loss, and diet quality. A medical care set is ordered involving laboratory testing, resting metabolic rate testing, obstructive sleep apnea screening, esophagogastroduodenoscopy (EGD), physical therapy assessment, and referral to our specialty services as needed (e.g., Endocrinology, Cardiology, Pharmacy). Documentation of medical necessity for bariatric surgery is provided for each patient.2. Nutrition. All patients undergo an initial individual nutrition evaluation with Courtney Young, RD, or Lori Solem, RD, and begin to practice the required lifestyle changes after this visit.3. Psychology. All patients undergo a psychological evaluation presurgery with Dr. Ames. The purpose of the psychology evaluation is not to deny access to care that patients need, but rather to address potential psychosocial needs and enhance patients’ confidence in their ability to adhere to recommended lifestyle changes.4. Group Education. Patients participate in eight hours of nutrition and psychology education presurgery. The nutrition sessions are designed to focus on the lifestyle changes required for optimal postsurgical outcome and to identify potential challenges to adherence to the recommended changes. The psychology sessions address expectations regarding weight loss, quality of life, body image. and relationships after surgery.1 Potential causes of weight regain after surgery like erosion of diet quality, inactivity, stress, sleep deprivation, and medications are also discussed.5. Insurance Predetermination. Following completion of the steps outlined above, patients’ medical necessity information is submitted to their insurance company by Ms. Franco. Upon receipt of insurance approval for surgery, patients are scheduled for a surgery consultation.6. Surgery. Patients meet with one of our surgeons for a discussion about the risks and benefits of bariatric surgery, informed consenting, and scheduling a date for the operation.7. Postoperative care. Patients are provided with detailed discharge instructions, an education booklet of dietary guidelines, and a follow-up phone call two weeks postoperative by the advanced practice providers. Patients have a visit at one month postoperative with their surgeon.8. Long-term Follow-up Care. Patients are seen for medical and nutrition follow up at 2, 6, and 12 months after surgery. These visits include laboratory tests and individual medical and nutrition visits to assess medication changes, weight loss trajectory, and nutritional status. Thereafter, patients are prescheduled for annual individual medical and nutrition visits.9. Postsurgery Support Groups. All patients are encouraged to attend our monthly support groups facilitated by Dr. Ames and Ms. Solem. We offer a maintenance group for patients who had surgery greater than 12 months prior and a group for patients who are less than 12 months out from having their operation. Each group offers a mini lesson by the facilitator and time for discussion, sharing, and questions. Two of our most popular and well-received topics in 2016 were: 1) “Is alcohol ever safe after bariatric surgery?”[2] and 2) “Plastic surgery after large weight loss” presented by our plastic surgery colleague, Dr. Sarvam P. TerKonda.

Quality Improvement
Our program is deeply committed to quality improvement. Our current quality improvement initiative is focused on reducing hospital readmission for nausea and vomiting in the first 30 days after the operation. The dietitians and surgical nurses educate patients about the signs and symptoms of dehydration in the few days to a month after surgery and provide handouts on this topic. Patients are encouraged to call the surgical nurse or advanced practice provider first before presenting to the emergency room. The surgical nurse will arrange an acute visit and, if needed, place orders for treatment in the hospital ambulatory infusion center, which offers extended patient care hours. The goal of this project is to reduce the frequency of emergency visits related to nausea, vomiting, and dehydration within the first postoperative month.

New TechnologiesEndoscopic Treatments. Our program now offers the ORBERA® intragastric balloon (Apollo Endosurgery, Inc., Austin, Texas) and the endoscopic sleeve gastroplasty performed by Victoria Gomez, MD, our gastroenterology colleague. These procedures are treatment options for patients struggling with obesity who either do not desire or who are not medically appropriate for a bariatric operation. Endoscopic sleeve gastroplasty has been performed for patients with BMIs between 30 and 40kg/m2 at our Mayo Clinic Campus in Minnesota since 2012 with promising weight loss results and improvements in metabolic profile.[3] Pouch revisions for lack of weight loss or weight regain after RYGB can also be performed endoscopically using a suturing device. Although this approach is less invasive and an outpatient procedure, results regarding effectiveness in terms of weight reduction are mixed. Patients with a large pouch and weight regain may be candidates for other revisions, but first must be re-revaluated by the entire multidisciplinary bariatric team.Robotics. Robotics using the daVinci Surgical System® is an attractive option for surgeons as it may improve safety and reduce the length of operating room time for bariatric surgery patients.[4] Dr. Elli has been performing robotic bariatric surgery for almost 15 years for primary operations including RYGB and DS. Since February 2016 when Dr. Elli became surgical director of our program, MSBAQIP data have shown a zero-percent leak rate, very low stricture rate, low rates of conversion to an open operation, and low blood loss for RYGB patients. Robotic operations are also useful in conversions where the anatomy may be obscured by scar tissue, and the complication rate for conversion operations is very low with good outcomes.[5] Other advantages of robotic operations for the surgeon include improved ergonomics, the possibility of controlling the camera, and the use of three active instruments, staplers and different energy sources. Also, the difficulties encountered in laparoscopic surgery like torqueing, suturing in difficult angles, large livers, and complications from previous surgeries are mostly overcome by the robotic system. Furthermore, muscle activation is greatly minimized during robotic surgery, thus reducing shoulder and back fatigue and discomfort after a full day of bariatric operations.

Unique Qualities of Our Program Collaboration with Transplant Program. The Mayo Clinic Campus in Florida has a large solid organ transplant program and the bariatric team receives referrals pre-transplant for patients suffering with obesity and end-stage organ failure. Some patients seeking transplant may be required to lose weight in order to receive an organ (e.g., heart, kidney, liver, lung) and the transplant team will refer these patients to the bariatric team for evaluation. One of the values critical to the mission of Mayo Clinic is commitment to teamwork; therefore, the transplant team is heavily involved in the management of their patients during bariatric procedures, improving safety and effectiveness of outcomes. Our program also cares for patients post-transplant who are struggling with obesity. Patients may suffer weight gain often related to use of antirejection mediations and the recurrence of diabetes or nonalcoholic steatohepatitis (NASH) putting the transplanted organ at risk.6 We have performed bariatric surgeries in many transplant patients with excellent results in terms of weight loss and preservation of organ health after transplant. Our team is open to receiving patients with a high degree of medical complexity. What we find most gratifying is offering hope to patients who were previously denied bariatric care at other programs because of the complexity and severity of their medical conditions.Patients with BMI of 60kg/m2 or greater. Patients with high BMIs are challenging but our multidisciplinary team has experience with performing operations on patients with BMIs of 60kg/m2 or greater with excellent results. We generally perform VSG as a first-stage operation. Depending on the patient’s weight loss achieved during the first 12-months and improvement observed in medical comorbidities, a second-stage operation, either RYGB or DS, is performed between 12 and 18 months after VSG.Conversions and Revisions. Patients come to our program as a last resort in many cases. Our surgeons are highly experienced and perform a wide variety of revisions and conversion operations that can be tailored to the needs of each individual patient. Revisions and conversions are most often performed for patients who were nonresponders to primary operations or suffered weight regain and return of medical comorbidities after initial successful weight loss.

Case Example
One of the most challenging cases Dr. Elli has performed thus far was a conversion from laparoscopic adjustable gastric band (LAGB) to VSG in a patient status post liver transplant. The patient was a 64-year-old male who underwent LAGB in 2008 at a weight of 260 lbs. He reduced down to 220 lbs. after three adjustments but quickly regained lost weight within two years after LAGB placement. The patient underwent liver transplant for hemochromatosis and NASH in 2014 at a weight of 261 lbs. One year after liver transplant, he developed diabetes and dysphagia induced by the LAGB with stenosis at the gastroesophageal junction. At one point, the patient suffered from meat impaction in his esophagus that required EGD for removal. The patient was frustrated with food intolerance and weight regain and desired removal of the LAGB with conversion to VSG. Furthermore, both the patient and his transplant team were concerned about the possible recurrence of NASH in his transplanted liver. Dr. Elli discussed with the patient in detail that a two-stage operation (i.e., LAGB removal stage one, VSG stage two) may be required if a large amount of scar tissue was found around the LAGB and stomach. During the LAGB removal, Dr. Elli decided that adhesions and a large amount of scar tissue around the LAGB did not safely allow for a one-stage operation. The LAGB removal was also challenging as it was located very high into the distal esophagus. After the LAGB removal, the patient returned four months later for stage two, a VSG. During the operation, a diagnostic laparoscopy showed multiple adhesions between the colon, omentum to abdominal wall, liver, and stomach requiring extensive lysis of adhesions to free the stomach from the transplanted liver. With very careful dissection of the stomach all the scar tissue was excised. The sleeve was then completed with minimal blood loss and in a minimally invasive fashion. The patient recovered very well. In the first month after his VSG, he lost 25 lbs. and discontinued his oral agent and long-acting insulin for diabetes control.

CONCLUSION
The Bariatric Surgery Program at The Mayo Clinic Campus in Florida is an integrated and multidisciplinary team offering specialty care for patients with clinically severe obesity. We perform primary operations, revision and conversion operations, as well as endoscopic procedures. Our team also has the experience and resources necessary to offer bariatric care to patients with complex and challenging medical conditions. New patients are welcome through either physician or self-referrals. Appointment requests can be made online at www.mayoclinic.org and through our Central Appointment office (904) 953-0853.

History of Bariatric Surgery

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